An 8 year old girl was brought to our casualty by her distraught parents with complaints that the child has been having severe joint pains and an unrelenting high grade fever since last 2 weeks. The child has also had multiple episodes of vomiting for the past 3-4 days. Her basic blood tests done showed a low hemoglobin (severe anemia), low platelet count (thrombocytopenia) and a very high white cell count (leukocytosis). Her further evaluation here confirmed the abnormal blood results, in addition to the highly deranged kidney functions. A quick look at the peripheral smear report in the laboratory raised the suspicion of an underlying leukemia (blood cancer). The production of abnormal WBC’s in leukemias can lead to a very high WBC count or sometimes even a low WBC count. We evaluated the child further with a bone marrow examination and confirmed the diagnosis of an acute Lymphoblastic Leukemia (ALL), one of the commonest blood cancers in children. Leukemia’s are cancer of the white blood cells and can be of different types for ex. an acute myeloid leukemia, an acute lymphoblastic leukemia and an acute Promyelocytic leukemia. All of these require urgent diagnosis and care, as they are highly curable if picked up early, and fatal if the diagnosis is delayed.
All types of blood cells are produced in the bone marrow and are reflected in the complete blood count (CBC) reports as hemoglobin, white blood cells and platelets. So if there is an abnormality in their production like in a leukemia, the abnormal cells many a times would be seen in the CBC. Also, when these abnormal white blood cells start multiplying in the bone marrow, they do not give space to the other blood cells (red blood cells and platelets) to grow and function. This is what causes the anemia and thrombocytopenia in such patients. In addition, the abnormal rate at which they grow causes an expansion of the bony cavities and thereby causing bony discomfort and pain that these patients present with. Since the WBC’s are the infection fighting cells of the body, their abnormalities affects the child’s immune system leading to an impaired ability to fight infections. Thus many a times, the high fever that these children present with is partly due to the infections that they develop due to their impaired immune system.
Leukemia’s can be Acute (sudden onset) or Chronic (longstanding). In children > 95% of leukemia are Acute. In comparison, adults have a higher incidence of chronic leukemia are more common and are called chronic lymphocytic leukemia and chronic myeloid leukemia.
An acute leukemia can be either of the two -
- Acute Lymphoblastic Leukemia
- Acute Myeloid Leukemia
Genetic mutations often cause most of these leukemias and can affect any socioeconomic strata. A strong family history of leukemia has also been reported to be a contributing factor.
The common signs and symptoms in leukemia present with include –
- Persistent unrelenting fever
- Easy bruising or bleeding
- Severe bony or joint pains
- Lumps in neck, underarm or groin
- Bloating of abdomen or stomach
- Inability to attend school or perform daily activities.
Some patients can also have unusual presentations like this 8 year old girl who came to the hospital in acute kidney failure, along with a low hemoglobin and platelet count. The cause of abnormal kidney functions in this child was mostly an overloaded kidney function that is struggling to remove the extremely high cellular contents that a leukemic cell releases into the blood circulation. This child completed her initial 6 month induction therapy, and is in a state of complete remission (No detectable disease). She has been started on maintainence therapy, which in an acute lymphoblastic leukemia lasts for 2 long years.
Leukemias need timely identification and characterization using a combination of simple tests like CBC, a peripheral smear and a bone marrow examination, and specialized tests like flow cytometry and Cytogenetics. With the correct treatment, 80 - 90 % of such children can be cured for life. Adolescents and adults have shown success rates ranging from 60 – 70%. Some patients based on the type of leukemia, might even require an allogeneic bone marrow transplant. Since the long duration of treatment can be financially and emotionally draining for the families, several such families receive financial support from NGO’s and several other organizations. In addition, patients and their families require a lot of social and psychological support to pull through these tough times. A comprehensive Hematology/Oncology unit therefore requires trained Pediatric/Adult Oncologist or Hematologists, specially trained nurses, a good intensive care unit backup, dedicated social workers, clinical psychologists and an organization tuned to cancer care.